Educational intervention to reduce inappropriate transthoracic echocardiograms: the need for sustained intervention.

BACKGROUND: We previously demonstrated that an Appropriate Use Criteria (AUC)-based educational intervention reduced inappropriate transthoracic echocardiograms (TTE) on an inpatient medical service. Whether improved TTE ordering is sustained after discontinuation of the intervention is unknown. METHODS: We conducted a prospective, time series analysis of an educational intervention designed to reduce inappropriate TTE. Ordering patterns during the intervention were compared with a preintervention control period and a postintervention period. The goal of the present analysis was to determine the TTE ordering patterns after discontinuation of the educational intervention. The primary outcome was the proportion of inappropriate TTEs. RESULTS: Using the 2011 AUC 99.2% of all TTEs were classifiable. Compared to the control, there was a 26% reduction in the number of TTEs ordered per day during the intervention (3.9 vs. 2.9 TTEs, P < 0.001), but no significant difference between the intervention and postintervention periods (2.9 vs. 3.1, P = 0.23). The intervention produced a decrease in the inappropriate TTE rate and an increase in the appropriate TTE rate. Compared to the intervention, in the postintervention period the rate of inappropriate TTEs increased (5% vs. 11%, P = 0.01) and appropriate TTEs decreased (93% vs. 86%, P = 0.008). The postintervention rate of inappropriate TTEs was similar to the preintervention control period (11% vs. 13%, P = 0.23). CONCLUSIONS: Following completion of an AUC-based educational intervention the proportion of inappropriate TTEs increased to the preintervention level. The long-term success of an intervention designed to improve appropriate utilization of TTE requires a sustained effort of education and feedback.

An Association Between Cardiologist Billing Patterns, Health Care Use, and Outcomes in Cardiac Patients.

BACKGROUND: Whether individual cardiologist billings are associated with differences in ambulatory care management and clinical outcomes in patients with coronary artery disease (CAD) and heart failure (HF) remains poorly understood. METHODS: We conducted a population-based, retrospective cohort study of cardiologists who treat patients with CAD or HF using administrative claims data in Ontario, Canada. The primary exposure was cardiologist billing quintile. We then stratified median billing amounts into quintiles, from lowest (quintile 1) to highest billing physicians (quintile 5). RESULTS: The main outcomes of interest were cardiac diagnostic and therapeutic procedures that occurred within 365 days of the index visit. Our 2 cohorts respectively consisted of 170,959 patients with CAD seen by 1 of 423 cardiologists and 56,262 HF patients seen by 1 of 413 cardiologists. CAD patients of higher-billing cardiologists had higher rates of echocardiograms (adjusted odds ratio [aOR], 1.65; 95% confidence interval [CI], 1.39 to 1.94 for quintile 5 vs quintile 2) and stress tests (aOR, 1.50; 95% CI, 1.28-1.75) at 1 year, with a similar pattern for HF patients of echocardiogram (aOR, 1.40; 95% CI, 1.23-1.59; P < 0.001) and stress test (aOR, 1.32; 95% CI, 1.15-1.51) use. CAD patients of cardiologists in quintile 1 had a higher mortality rate (aOR, 1.16; 95% CI, 1.03-1.31), and HF patients of cardiologists in billing quintile 4 had a lower hospitalization rate at 1 year (OR, 0.94; 95% CI, 0.89-0.99; P = 0.02). CONCLUSIONS: Cardiac patients seen by the highest-billing cardiologists received more noninvasive cardiac testing compared with lower-billing cardiologists.

INTRODUCTION: On comprend mal que la facturation individuelle des cardiologues soit associée à des différences dans la prise en charge des soins ambulatoires et les résultats cliniques des patients atteints de coronaropathie et d'insuffisance cardiaque (IC). MÉTHODES: Nous avons mené une étude de cohorte populationnelle rétrospective auprès de cardiologues, qui traitent les patients atteints de coronaropathie ou d'IC, à partir des données sur les réclamations administratives en Ontario, au Canada. La principale exposition était les quintiles de facturation des cardiologues. Nous avons donc stratifié les montants médians de la facturation en quintiles, soit des médecins qui facturaient le moins (quintile 1) aux médecins qui facturaient le plus (quintile 5). RÉSULTATS: Les principaux critères d'intérêts étaient le diagnostic de cardiopathie et les interventions thérapeutiques qui survenaient dans les 365 jours de la consultation indicielle. Nos deux cohortes regroupaient respectivement 170 959 patients atteints d'une coronaropathie qui avaient été vus par un des 423 cardiologues et 56 262 patients atteints d'IC vus par un des 413 cardiologues. Les patients atteints d'une coronaropathie des cardiologues qui facturaient le plus avaient des taux plus élevés d'utilisation des échocardiogrammes (rapport de cotes ajusté [RCa], 1,65; intervalle de confiance [IC] à 95 %, 1,39-1,94 pour le quintile 5 vs le quintile 2) et des épreuves d'effort (RCa, 1,50; IC à 95 %, 1,28-1,75) après 1 an, et les patients atteints d'IC avaient un profil comparable d'utilisation des échocardiogrammes (RCa, 1,40; IC à 95 %, 1,23-1,59; P < 0,001) et des épreuves d'effort (RCa, 1,32; IC à 95 %, 1,15-1,51). Les patients atteints d'IC des cardiologues dans le quintile 1 avaient un taux de mortalité plus élevé (RCa, 1,16; IC à 95 %, 1,03-1,31), et les patients atteints d'IC des cardiologues dans le quintile de facturation 4 avaient un taux d'hospitalisation plus faible après 1 an (RC, 0,94; IC à 95 %, 0,89-0,99; P = 0,02). CONCLUSIONS: Les patients cardiaques vus par les cardiologues qui facturaient le plus avaient plus d'examens non invasifs du cœur comparativement aux patients vus par les cardiologues qui facturaient le moins.

TNF-α (g.-308 G > A) and ADIPOQ (g. + 45 T > G) gene polymorphisms in type 2 diabetes and microvascular complications in the region of Punjab (North-West India).

AIMS: The present study aims to examine the association of tumor necrosis factor-α (TNF-α) g.-308 G > A and adiponectin (ADIPOQ) g. + 45 T > G gene polymorphisms in type 2 diabetes (T2D) and its microvascular complications diabetic retinopathy (DR) and diabetic nephropathy (DN). MATERIALS AND METHODS: A total of 672 individuals were analysed from the North-West population of Punjab. Genotyping was accomplished by a combination of allele specific amplification refractory mutation system and restriction digestion for TNF-α g. - 308 G > A and ADIPOQ g. + 45 T > G polymorphisms, respectively. Further, in silico modeling was done to predict secondary structure of mRNA for g. + 45 T > G polymorphism in the ADIPOQ gene by RNA fold. RESULTS: The minor allele frequency observed in the controls for the TNF-α G > A and ADIPOQ T > G polymorphisms were 0.07 and 0.10, respectively. The results show no significant association with TNF-α g. - 308 G > A polymorphism in T2D as well as in any of the microvascular complication. However, the ADIPOQ g. + 45 T > G polymorphism shows significant association in T2D (p = 0.048) and DR (p = 0.001) but in DN patients, no association was observed. Interactive analysis revealed that the two polymorphisms jointly conferred a 1.45-fold risk towards the occurrence of T2D [p = 0.031; OR = 1.45 (1.03-2.05)]. In the secondary structure of mRNA, slight free energy change was observed between the wild ( - 1370.28 kcal/mol) and variant allele (-1369.08 kcal/mol). CONCLUSIONS: Our results indicated a higher risk of T2D and DR in the background of ADIPOQ TT genotype. Further, the ADIPOQ g. + 45 T > G and TNF-α g. - 308 G > A polymorphisms jointly give 1.45-fold risk towards T2D.

Use of an interdisciplinary, participatory design approach to develop a usable patient self-assessment tool in atrial fibrillation.

After identifying that significant care gaps exist within the management of atrial fibrillation (AF), a patient-focused tool was developed to help patients better assess and manage their AF. This tool aims to provide education and awareness regarding the management of symptoms and stroke risk associated with AF, while engaging patients to identify if their condition is optimally managed and to become involved in their own care. An interdisciplinary group of health care providers and designers worked together in a participatory design approach to develop the tool with input from patients. Usability testing was completed with 22 patients of varying demographics to represent the characteristics of the patient population. The findings from usability testing interviews were used to further improve and develop the tool to improve ease of use. A physician-facing tool was also developed to help to explain the tool and provide a brief summary of the 2012 Canadian Cardiovascular Society atrial fibrillation guidelines. By incorporating patient input and human-centered design with the knowledge, experience, and medical expertise of health care providers, we have used an approach in developing the tool that tries to more effectively meet patients' needs.